Pituitary stone--case report

Pituitary stone resulting in visual dysfunction and spontaneous rhinorrhea in nonfunctioning pituitary adenoma: illustrative case

BACKGROUND

Calcifications in pituitary adenomas are rare, being found in only 5.4%–25% of reported cases. These are divided into eggshell-like calcifications around the tumor and nodular calcifications at the center of the tumor, the latter of which are called “pituitary stones” (PSs).

OBSERVATIONS

The authors report the case of a 60-year-old male with a nonfunctional pituitary adenoma with PSs and asymptomatic ventricular dilatation who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhea and rapid visual aggravation without an increase in tumor size over the course of 4 years. After endoscopic transnasal surgery, his visual acuity immediately improved temporarily. It was believed that the increased intracranial pressure due to secondary hydrocephalus resulted in visual aggravation; thus, a ventriculoperitoneal (VP) shunt was created. After creation of the VP shunt, the patient’s visual acuity improved gradually and completely. Histological findings showed that adenoma cells were observed among the lamellar bone trabeculae. To the best of the authors knowledge, this is the first report of osteoid metaplasia–type PSs in nonfunctioning pituitary adenoma.

LESSONS

PSs formed near the sellar floor and caused spontaneous CSF rhinorrhea due to direct mechanical stress on the dura mater and optic nerves, which may have caused meningitis and secondary hydrocephalus that resulted in visual impairment independent of tumor size.

Endoscopic endonasal resection of nonfunctioning pituitary adenoma with radiological calcification

OBJECTIVE

Radiological calcification in nonfunctioning pituitary adenoma is scarcely rare, which appears in various formations and raises special diagnostic and therapeutic challenges. Here we present our experience about the clinical aspects and treatment of calcified nonfunctioning pituitary adenoma.

METHODS

A total of 145 patients who underwent surgical resection of nonfunctioning pituitary adenomas via endoscopic endonasal approach from February 2008 to December 2018 were reviewed. Among these patients, cases with radiological calcifications on preoperative imaging were included in this study. We analyzed these patients' records, radiological neuroimaging, endocrine evaluation, operative notes as well as intraoperative videos.

RESULTS

Calcification on preoperative neuroimaging was observed in only 7 patients with nonfunctioning pituitary adenomas. The study population consisted of these seven patients with intra-tumor calcification (n = 2), thin and egg shelf-like capsular calcification (n = 3), hard and armor-like capsular calcification (n = 2). In 85.7% of cases (n = 6), nonfunctioning pituitary adenomas with calcification were characterized by soft tumor texture. Evidences demonstrated apoplexy occurred in 71.4% of cases with calcified pituitary adenomas (n = 5). Patients with intra-tumor calcification as well as with thin and egg shelf-like capsular calcification underwent resection of both tumor and calcification through extra-pseduocapusual dissection via endoscopic endonasal approach. Besides, in the remaining 2 cases (28.6%), hard and armor-like capsular calcification was found surrounding a soft tumor component; however, it did not interfere with adequate removal of the soft part via endoscopic endonasal approach with the hard calcification untouched. Postoperative course of all patients was uneventful. Long term follow-up (median interval of 49 months, range 8-70 months) showed that no recurrence occurred.

CONCLUSIONS

Although relatively rare, calcified nonfunctioning pituitary adenoma should be kept in mind to avoid making a wrong preoperative diagnosis. Given various calcification types, multiple surgical tactics is required accordingly. Extra-pseudocapusual resection via endoscopic endonasal approach is helpful for the resection of both adenoma and calcification.

Endoscopic Endonasal Removal of Large Calcified Pituitary Adenoma: Case Report and Review of the Literature

BACKGROUND

Large calcified intrasellar masses, called pituitary stones, have been reported as calcified pituitary adenomas in the literature. Although relatively rare, calcified pituitary adenomas appear in various formations. Thus, whether the lesion is removable-and, if so, which approach is appropriate-mainly depends on its formation and quality.

CASE DESCRIPTION

A 46-year-old woman presented with visual loss and amenorrhea. Although computed tomography showed a uniformly calcified sellar tumor, magnetic resonance imaging displayed heterogenous intensity on T2-weighted images and mild gadolinium enhancement, suggesting that the lesion was a mixture of pituitary adenoma and fine calcification. Thus, we undertook tumor resection via an endoscopic endonasal approach, which resulted in total removal. The pathological diagnosis was a pituitary adenoma with rich calcification.

CONCLUSIONS

We report a rare case of a large pituitary stone that was successfully removed via an endoscopic endonasal approach. This could therefore be a feasible, effective technique for the removal of pituitary stones, although careful analysis of preoperative magnetic resonance imaging is required.

Gigantism in a McCune-Albright's syndrome with calcified GH-releasing pituitary adenoma: Case report and literature review

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There have been very few cases of pituitary calcified associated with McCune Albright syndrome.

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Pituitary calcification is quite rare by itself.

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Unlike this is a benign disease, its behavior is very aggressive and this highlights the need of a multidisciplinary team.

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It is mandatory to rule out a whole work up when McCune Albright syndrome is suspected to stratify risks and survival.

Background

McCune-Albright’s syndrome (MAS) is a rare disorder that is characterized by café-au-lait macules, fibrous dysplasia of the skull and endocrinopathies like excessive secretion of growth hormone by a hyper-functional pituitary adenoma (PA).

Case

We describe the case of a 43-year-old male with history of Gigantism in 1990 secondary to a GH-secreting pituitary macroadenoma that was treated via microscopic transsphenoidal surgery at that time.

He was reported as asymptomatic for 26 years until he developed headache and right temporal hemianopia with left amaurosis. Also ptosis and proptosis was found caused by a re-growth of the tumor on the follow up MRI.

A second surgical procedure was performed via a dorsolateral craniotomy. Gross total resection was also achieved with a Neuropathology report of a pituitary adenoma tissue accompanied by extended dystrophic calcification and bone formation.

Conclusion

This is a rare case of MAS. Gigantism within the context of a pituitary calcification raises special diagnostic and therapeutic challenges. The cause of the excessive secretion of GH in MAS is not well understood concluding that it seems to be a different etiology of patients with Acromegaly and Gigantism in non-MAS patients.

Clinical characteristics of pituitary adenomas with radiological calcification

BACKGROUND

Radiographic detection of calcification in pituitary adenoma is relatively rare, and the clinical characteristics of pituitary adenoma with calcification remain unclear. Herein, the clinical characteristics of pituitary adenoma with radiological calcification were investigated.

METHODS

A total of 160 patients who underwent surgical resection of pituitary adenomas between February 2004 and December 2016 were reviewed. Eighty-one patients had hormone-secreting pituitary adenomas, and 79 patients had nonfunctioning pituitary adenoma. Among these 160 patients, cases with radiological calcifications on preoperative neuroimaging were included in this study, and clinical characteristics with intraoperative findings were analyzed, retrospectively.

RESULTS

Pituitary adenoma with calcification on preoperative neuroimaging was observed in only nine cases (5.6%). The study population consisted of these nine patients with nonfunctioning pituitary adenoma (n = 5), mixed growth hormone and prolactin-secreting pituitary adenomas (n = 3), and a prolactinoma (n = 1). In 89% of cases (n = 8), calcified pituitary adenoma was soft enough for suction despite the presence of a granular gritty texture intraoperatively. Besides, in a single patient (11%), evidence of hard thick capsular calcification was seen surrounding a soft tumor component; however, it did not interfere with adequate removal of the soft part, and tumor resection was possible in all cases without any complications.

CONCLUSIONS

Pituitary adenoma presenting with calcification is relatively rare, but should be kept in mind to avoid making a wrong preoperative diagnosis. As not all pituitary adenomas with calcification are hard tumors, preoperative radiological calcification should not affect decision-making regarding surgical indications.

Dense calcification in a GH-secreting pituitary macroadenoma

A 30-year-old female presented with a history of secondary amenorrhoea, acromegalic features and progressive visual deterioration. She had elevated serum IGF1 levels and unsuppressed GH levels after an oral glucose tolerance test. Magnetic resonance imaging revealed a heterogeneously enhancing space-occupying lesion with atypical extensive calcification within the sellar and suprasellar areas. Owing to the extent of calcification, the tumour was a surgical challenge. Postoperatively, there was clinical, radiological and biochemical evidence of residual disease, which required treatment with a somatostatin analogue and radiotherapy. Mutational analysis of the aryl hydrocarbon receptor-interacting protein (AIP) gene was negative. This case confirms the relatively rare occurrence of calcification within a pituitary macroadenoma and its associated management problems. The presentation, biochemical, radiological and pathological findings are discussed in the context of the relevant literature.

Pituitary gland: development, normal appearances, and magnetic resonance imaging protocols

In this article, I will review the normal anatomy of the pituitary gland starting with a brief review of aspects of its origin and development that are pertinent to radiologists. The anatomy of the anterior and posterior lobes will be addressed as will be that of the surrounding structures and of the vascular structures of the gland. Radiologists need to be familiar with the normal magnetic resonance imaging appearance of the gland and the changes that it undergoes throughout life. The normal patterns of contrast enhancement by the gland are described. Normal pituitary variations and incidental conditions are discussed, and the article finishes by describing appropriate imaging protocols.